Personality, Lifestyle, and Death
Richard S. Perrotto
In the history of mankind, it is
difficult to find a topic more ancient than death and dying. This
topic has persistently occupied the thoughts of philosophers,
theologians, scientist, and most certainly the average human being.
Scientific investigation of this topic did riot begin in earnest until
the mid-1950's for reasons yet open to conjecture. Certainly, the
Freudian notion that we cannot accept our own mortality since we
cannot "know" death has provided a quick and convenient rationale for
skirting the issue (Freud, 1915, 1917). The idea that we cannot "know"
death is also found in the writings of the eminent suicidologist
Edwin Shneidman who wrote that people can only "know" death as one
experience the death of another, or as one anticipates it for himself
(1973). The latter is what Sneidman calls "knowledge through the
Postself"; the current anticipation of what the world will be like
when the person is absent from it and how his fame, reputation, and
impact. will be perceived. The Postself may be inscribed in: a. the
memories of others; b-the stimulation of the works and deeds of others
through one's own works; c. the bodies of others through organ
transplantation; d. the genes of one's progeny and e. the cosmos as
part of the universe. According to Shneidman, if one could experience
death directly, one would not be dead! This attitude toward death has
helped foster the reputation of our society as death-defying and
death-denying. It can be clearly seen in Judeo-Christian beliefs that
stress eternal life even if corporeal existence is ephemeral, and in
the euphemistic verbalizations that refer to death as expiration,
being deceased, passing away, and in the usual device of avoiding
reference to the term death altogether for fear that such
usage may actualize it. Death-denying and defying is also conspicuous
in the practices of physicians and other "healing" professionals where
new life-extending techniques abound in a seemingly vain attempt to
prevent (or at least postpone) what no person can.
Given that we live in a death-denying
society, a death awareness movement has been counterposed in an
attempt to deal directly with a human concern for the plight of the
dying person. One of the basic tenets of this movement maintains that
since death is inevitable, it would be counterproductive to deny in
it. In fact, it would be more humane and therapeutic to prepare for
it. Moreover, the imminence of depth can be assuaged if the individual
is permitted to die appropriately. Weisman (1972) defined "appropriate
death" as "one in which there is reduction of conflict, compatibility
with the ego ideal, continuity of significant relationships, and
consummation of prevailing wishes." In short, an "appropriate death"
is one which a person might choose for himself had he an option. It is
riot merely conclusive; it is consummatory. An "appropriate death" is
as painless as possible to the individual, his postself, and
significant others in his life. Undoubtedly, the most popularized
position on "appropriate death" is that of Elizabeth Kubler-Ross whose
work On Death and Dying (l969) is considered by many to be one
of the first and most important in the humanistic death awareness
Kubler-Ross contends that there are
five stages of dying from a psychological perspective. At points along
this process, appropriate psychiatric interventions are implemented
toward the end of acceptance. Generally, those working with the dying
person try to be as open as possible about death .in ~: manner that is
considerate of the person's plight and his ability to assimilate
information. If one operates under the assumption that on some level
the person "knows" he is dying, how the information is presented and
how the person may maneuver it is an important concern. Basically,
people hear what they want to hear in a way that is consistent with
their current orientation to the world. The five stages of dying can
be outlined as follows:
1. Denial - a basic
refusal to believe that he is dying despite overwhelming medical
2. Anger - person begins
to face reality and angrily questions why it had to happen to him.
3. Bargaining - patient is looking for
ways to buy more time or effect some trade-off or compromise.
4. Depression - person
desponds because of the realization that death is imminent and
bargaining is unrealistic.
5. Acceptance –
is reached when the person realistically appraises
that he has done everything possible and now - "so be it". This stage
is beyond affect since the reasons for negative emotional response
have been worked through.
While the goal of treating the dying
person with dignity may be served by Kubler-Ross, Shneidman (1973)
echoes common criticisms that while dying people may be seen
bargaining, depressed, and denying, that is not proof that there are
stages of dying nor that they are experienced in that order or in any
universal order. Shneidman (1973)
and Weisman (1972) are
more inclined to view the dying process as an ebb and flow or waxing
and waning of disbelief and hope, denial and acceptance. Others have
leveled criticisms stating that the "stage theory" does not consider
the significance of the preterminal personality and other life history
factors in addition to other peculiar situational determinants such as
the actual disease process and the nature of treatment (Kastenbaum and
Costa, 1977). "Stage theory"
may in fact be divorced from the context of the person's past and
present life. The greatest danger may lie in the conversion of an
untestable theory into a recipe for perfect or desirable death.
Side-by-side with the death awareness
movement is an apparently contrary movement based on the idea that
death and dying are the culmination of the effects of particular
personalities and lifestyles (P/LS) on physiological integrity. If
death and dying can be attributed to P/LS, it follows that people
contribute to their own demise. If P/LS can produce demise, then it is
conceivable that people can learn to change those variables and
thereby defy death. Therefore, at issue is whether psychological
factors, i.e., emotions, perceived stress, cognitions, attitudes and
behavioral propensities can contribute to-physical disease, dying and
ultimately death. If so, what premorbid characteristics might be
predictive?; is there scientific evidence to support this position?;
how can knowledge of such factors be translated into a therapeutic
regimen either in prevention or secondary and tertiary treatment?; is
it ethical to encourage death-defying especially in light of the
death-awareness movement? The remainder of this chapter will be
devoted to the exploration of these questions.
of the pronouns "he" and "his" are not intended to be discriminatory.
It is a matter of habit and writing comfort.
PHILOSOPHICAL NOTIONS AND HOLISTIC MEDICINE
Western thought has been influenced by
the Cartesian dualism of mind and body which views mind and body as
distinct entities each "knowing” a different reality. The body can only
"know" physical reality while the mind can only "know" metaphysical
reality. Certainly, the mind can "know" of the body and vice versa, but
neither can "know" of the other in the same way that each "knows" of
itself. This line of reasoning has fostered a dichotomous view of human
nature as evidence by language which reserves different terms to denote
the different entities; mind and body. It is clearly demonstrated in the
way in which certain sciences are segregated. Physicians investigate
physical disease and tend to view and thus treat people as mechanical
entities while psychologists investigate mental realities and tend to
see people in terms of intangibles such as thoughts, feelings, and
personality traits.2 Unfortunately, too many physicians tend to ignore
the potential role of P/LS in physical disease while too many
psychologists tend to ignore the contributions of physical factors in
understanding "mental" functioning.
Despite the perceived segregation of mind
and body in Western thought, it is commonly held that mind does interact
with body and despite the lack of substantial medical evidence people
often perceive their physical condition as deriving from psychological
forces. Such people also tend to see their "cure" as being partially
dependent on "taming" these psychological forces. These views have
crystallized in the Holistic Medicine movement which holds that an
individual's condition results from the fine interplay of psychological
and physiological factors in a reciprocal manner. Any attempt to
explain or treat disease in terms that fail to consider the person as a
whole functioning organism would be deficient. In his book, Mind as
Healer, Mind as Slayer (19?"' Kenneth Pelletier
contends that "all disorders are psychosomatic in the sense that both
mind and body are involved in their etiology. Any disorder is created
out of a complex interaction of social factors, physical and
psychological stress, the personality of the individual subjected to
these influences and the inability of the individual to adapt
adequately to pressures. Once illness is viewed as a complex
interaction of these factors, then it is possible to view symptom as an
early indication of excessive stain upon the mind-body system.
(Pelletier, 1977, P. 13).
• This is not to say
the psychologists have not also adopted a mechanical model of mind; many
The Holistic approach is the cornerstone
of an emergent field called Behavioral Medicine, an interesting
interdisciplinary approach encompassing the behavioral and biological
sciences united to the goal of understanding, predicting and treating
disease. A necessary ingredient of the behavioral approach to treatment
is the concept of self-control. In strict behavioral terms, a person
does not "have self-control in the sense of some internal trait. He
learns it. Stated more broadly, if a person learned a maladaptive
lifestyle, and it is that lifestyle that has contributed to disease,
then the person may learn more adaptive coping skills and thereby
prevent or ameliorate disease. Rather than accept death, the individual
in recognition of his own contribution to the dying process, may learn
to defy death. This fits nicely with a recently advanced notion by
Bandura, a cognitively-oriented therapist, that the common denominator
of effective psychotherapy is a sense of "self-efficacy". This refers to
the expectation a person develops that he not only knows what to do to
get better but also knows that he possesses the wherewithal to perform
the necessary behaviors (Bandura, 1977). Bandura makes the point that
most patients either know what to do in order to produce certain
favorable outcomes or at least can recognize the possible utility of
the therapist's advice. However, change does not occur until the person
believes he has developed the skills necessary.
Finally, I would like to point out that
the recognition of psychological factors in the etiology of physical
disease is also expressed in the official nosological system of the
American Psychiatric Association (APA-DSM-III, 1980). The DSM-III allows
for diagnoses of "Psychological Factors Affecting Physical Condition".
Here, the diagnostician can specify a particular disease such as ulcer,
migraine, hypertension, tachycardia, etc., considered by clinical and
experimental evidence to be symptomatic of maladaptive mind-body
RESEARCH RELATING P/LS AND DISEASE
Certainly all lifestyles terminate in
death and many of those who die have succumbed to disease. It is
possible that how and when people die may be traceable to particular
personality characteristics and lifestyles. Intuitively this idea is
sensible, yet most scientific attempts have failed to clarify the
precise cause and effect relationships necessary to unequivocally make a
point. Among the numerous stumbling blocks to scientific verification,
one is salient. Most studies attempting to link psychological factors to
disease are retrospective in design. The researchers assemble a sample
of diseased individuals and then assess past and present P/LS in the
hope of discovering a connection. The retrospective approach is
nearly analogous to fishing. Just as the fisherman casts a bait-laden
hook into the lake hoping to catch a fish, the retrospective researcher
observes the diseased and dying person and hopes to disentangle the
multitude of possible etiologic factors in a "sea" of possibilities.
Such research is relatively risk-free in the sense that the researcher
need not necessarily make any specific predictions. It is easy to make
claims after the fact. However, it is nearly impossible to determine
cause and effect. What the researcher is usually left with is a disease
state, dying patients and speculations regarding associations among
possible etiologic factors. The researcher may in fact be looking at
factors related to other variables not being observed or the cognitive
emotional by-products of disease. The possible solution resides in
identifying some of the more strongly associated factors and then
observing their presence in the premorbid personality as predictors of
future disease states. This is a prospective study; difficult to
conduct, time consuming, but definitely in order.
One example of how this has been employed
is in the study of Coronary Heart Disease (CHD). It is well known that
CHD (angina pectoris, myocardial infarction, hypertension, congestive
heart failure, etc.) can be crippling and deadly, afflicting roughly 3%
of American adults past the age of 30. While numerous factors such as
smoking, diet, lack of exercise and genetics have been implicated in CHD
etiology, it has been suggested that
P/LS plays an important developmental role. Friedman and Rosenman, two
San Francisco cardiologists, began to study this relationship in the
and 1960's and in
1974, published Type A Behavior
and Your Heart, wherein they identified the prospective CHD
patient as suffering from time urgency, impatience, ambition,
competitiveness,, and unrecognized hostility. Subsequently, such
adjectives as aggressive, dominant, quick-thinking, self-confident,
autonomous, extroverted, changeable, and adventurous were added (Chesney,
et al., 1981). The Type-B person
presents the opposite characteristics. Several prospective studies have
apparently confirmed the connection (Chesney, et al.,
1981). While flaws in the
research methodology render the connection hazy, it is clear that the
P/LS characteristics outlined do play some causal role even if not an
all-determining one. Identification of these characteristics is
important not only from a descriptive-predictive point of view, but also
as target variables for psychotherapeutic interventions. One particular
problem in using this knowledge to devise a treatment program is that
the Type-A person is not likely to see himself as having a problem and
therefore not likely to seek treatment.
P/LS AND SUICIDE
Suicide presents the
clearest example of how P/LS produce death. But what about deaths that
invite psychological explanation? I am specifically referring to cases
in which the mode of death is equivocal. For economic, political and
legal reasons beyond the purview of this chapter, deaths are
typically classified as Natural (N), Accidental (A), Suicide (S), or
Homicide (H); hence the NASH designation according to Shneidman
However, the cause of death certified on a Death
Certificate does not always provide specific information regarding the
mode of death and in roughly 10-15% of all cases, the mode of death is
equivocal due to paucity of information, an inadequate psychological
investigation or both. This is painfully obvious in trying to ascertain
suicide vs. accident but equally curious in cases of natural death if
P/LS contribute to one's demise. For example, if a person is found dead
in a fire, death may be accidental. But it could be a homicide
at the hands of an arsonist. More
boggling is the possibility that the person set the blaze
intentionally, in which case it could be a suicide! Even if no conscious
process could be deduced, can we rule out the possibility
of a subintentioned inclination to die which in turn was manifested
in poor judgment and carelessness with flammable items?
As another example which integrates the
previous discussion with CHD, might not the Type-A personality be
affecting his own demise through some intentional or sub-intentional
proclivity? The principal shortcoming of official death certifications
of death is that they fail to specify intention. A boy who drowns
in a pool may have been rushed, may have jumped, or may have been
careless. A precise certification depends on assessment of intent; a
monumental task considering that the prime source of information -- the
deceased -is dead!
Since the HASH designation is basically
Cartesian in nature, one must appeal to other approaches. One such
approach is the "Psychological Autopsy" which reconstructs the role
played by the deceased in his own death (Shneidman,
1969). Before describing the
"Psychological Autopsy", an analysis of intention is necessary.
Shneidman (1973) contends
that in order to fathom the concept of death and intention
one must recognize the contrary emotions that people experience
simultaneously; pleasure-pain, love-hate, wish-fear, life-death --
ambivalence. As Shneidman puts it, "One can swallow a pill, genuinely
wishing to die, and at the same time, hope for rescue" (Shneidman,
1973, P. 82). While the concept
of ambivalence is fundamental to Psychodynamic theory, one need not
subscribe to the Freudian concepts of life and death instincts,
libido, or death wish. Ambivalence might be easily
reconceptualized in a number of ways and still retain its essence. The
point is that people may, to varying degrees, knowingly and unknowingly,
contribute to their own demise.
Shneidman distinguishes several
personality types where intention is reasonably clear
(1973). There is the:
1. Death-Seeker - who
consciously behaves in such a way as to bring about his death. Method is
irrelevant. What matters is that the person
single-mindedly behaves in a way that makes it nearly impossible for
people to save him. Tomorrow he may actively resist death, but today he
actively seeks it.
2. Death-Initiator - who
knows that his days are numbered or that he is deteriorating and cannot
live with that.
3. Death-Ignorer (transcender) who
believes that after he terminates his life by suicide he will continue
to exist in some other way such as in the afterlife.
4. Death-Darer - who
essentially is playing "Russian Roulette" with his life. This person
engages in "dare-devil" activities where he stands a low probability of
surviving because of a lack of skill necessary; to succeed. This person
is "flirting with death".
Of course, most deaths are not suicides,
corning; as a result of violence or natural causes and as far as the
individual is concerned, they are unintentional in that the person was
not consciously trying to kill himself. With unintentional deaths there
1. Death-Welcomer - who
after a long incapaciting illness welcomes the relief that death
2. Death-Postponer - who
hopes it will not come sometime soon and does
what is possible to delay it.
3. Death-Accepter - who has
resigned himself to death.
4. Death-Disdainer - who
momentarily contemplates death yet believes he is beyond any involvement
in the death process.
5. Death-Fearer- Who is almost
phobic about death or any reference to it.
6. Death-Feigner- Who cries “Wolf”
for the purpose of manipulating others.
(1973) also talks of
subintention -- an unconscious motive to kill oneself evidenced by poor
judgment, imprudence, high sensation-seeking and risk-taking, personal
neglect and abuse such as drug and alcohol taking. Subintention may
play a significant role in all four of the NASH categories. Shneidman
also views "voodoo deaths", unexplained hospital deaths, and sudden
deaths in apparently healthy individuals as attributable to subintention.
He also cites accidental death in "accident-prone" people and
"victim-precipitated" homicide as suggestive of subintention. Clearly,
"accident-prone" is a contradiction in terms implying a personal
involvement in the "accidental" event. In "victim-precipitated"
homicide, it is powerfully suggested again that the person did something
to provoke the homicidal event although there may be no conscious
awareness of intent. People who drive recklessly, abuse drugs, frequent
crime-beleaguered neighborhoods, or provoke aggressive behaviors in
others seem to invite death. Shneidman identifies the following
1. Death-Chancer - who
gambles with death. He is more likely to die than the Death-Darer
because he requires significantly greater odds that he will live. His
life is left to chance.
2. Death-Hastener - who
unconsciously brings about death by irritating an existing abnormal
physiological condition through bodily abuse and/or mismanagement.
- who does not resist death. By passively succumbing to his
condition, he makes it easy for death to occur. In this regard,
Seligman's "learned helplessness" model is relevant (1975). According
to Seligman, depression results when an individual believes that he no
longer has any control over what happens to him. He has learned from
experience that he is ineffectual and that the locus of control has
shifted to agents in the external world, rendering the person helpless
and his future hopeless. Even when the opportunity to remedy one's
situation exists, the person does not respond owing to his negative
cognitive set. The person may then lose his will to live, thereby
facilitating death. Farber (1968)
has presented a similar view in which he construes suicide as a
"disease of hope". According to the hypotheses, suicides are committed
by people who are psychologically damaged and confronted by a
del3rivation situation. Suicide (S) is a function (f) of vulnerability
(V) and deprivations (D); S=f(VD). This is consistent with certain
Behavioral conceptions of depression which hypothesize that depression
results from a reduction of positively reinforcing behaviors (Ferster,
1965, 1973; Lewinsohn,
1974) or a reduction in
reinforcer effectiveness (Costello,
1972). In either case there is a perceived sense of hopelessness
and helplessness which may result in the loss of the will to live.
4. _Death-Capitulator - who
through fear of death arouses strong emotions that affect his
- who lives on the edge of death by subintentionally
wishing for a permanently altered state of consciousness. This person
experiments with drugs and alcohol, always running the risk of
converting his altered state into coma and death.
This type of death is usually considered to be accidental.
Since many deaths are equivocal with
regard to mode, it is necessary to retrospectively assess P/LS with the
"Psychological Autopsy". Data to be included would be:
l. Identifying information for the victim
(name, age, address, marital status, religious practices, occupation,
2. Details of death (cause, method,
Historical information (sibs, marriage, medical illnesses,
medical and psychotherapy, suicidal attempts or gestures).
4. Death history of victim's family
(suicides. cancer, other fatal illnesses, age at death).
Description of personality and lifestyle.
Victim's characteristic reactions to stress.
7. Any recent upsets, pressures,
tensions, or anticipations of trouble.
8. Role of alcohol or drugs in a) overall
lifestyle b) death.
Nature of victim's interpersonal relationships.
10. Fantasies, dreams, cognitions,
premonitions or fears relating to death, accident or suicide.
11. Before death changes in habits,
hobbies, sexual pattern or other life routines.
12. information about upswings,
13. assessment of intention.
14. Rating of lethality, i.e., intent to
die in terms of low, medium, or high.
15. Reaction of informants to victim’s
death (Shneidman, 1969, 1973).
Such a retrospective account may then be
pooled with other “Psychological Autopsies” in the hope of finding
predictors of future suicide. While Suicidology is far from an exact
science, the information culled from such a procedure may yet prove
useful in identifying lifestyles of persons who are at risk.
P/LS AND CANCER
The main thread drawn through this entire
chapter is that people contribute to their own demise and in keeping
with our death-denying attitude I will present evidence to show that
P/LS may contribute to the incidence, course, and treatment of cancer.
It is not at all unreasonable that the "Psychological Autopsy" and
corresponding death-types defined by Shneidman can be applied to
"natural deaths" resulting from cancer and disease in general. One of
the more celebrated cases involving psychosomatic disease is the account
of Norman Cousins (1976). In 1964, Cousins
developed a comprehensive,
degenerative collagen disorder called Ankylosing Spondylitis. He
experienced extreme difficulty in initiating movement, nodules appeared
under the skin, and his jaws nearly locked. He was informed that his
chances of recovery were, at best, 1 in 500. Through discussions with
medical specialists and his own reading, Cousins formed the hypothesis
that his condition probably resulted from heavy-metal poisoning
interacting with a predisposing lowered resistance to bodily insult.
He presumed that his lowered resistance was "adrenal exhaustion" owing
to his laborious stressful work demands. He reasoned that his cure
required a restoration of normal adrenal functioning. With the
supervision of a rather open-minded physician, Cousins' therapeutic
regimen consisted of mega-doses of vitamin C and positive emotions. If
stress an negative emotions contributed to the illness, it was
reasonable to assume that positive emotions would contribute to his
recovery. This facet of therapy involved a positive attitude, the will
to live, hope, faith, and watching episodes of "Candid Camera". Slowly
but surely, Cousins' condition went into remission and he fully
recovered. According to Cousins, the prime ingredient was his belief
that he could and would get better; something that was more than an
abstraction but rather a physiological reality.
Cousins' account has
been harshly criticized recently by the sociologist F. A. Ruderman. It
is her contention that the diagnosis was never certain and that the
disease may have been nothing more than an acute attack of arthritis
which subsided spontaneously (Holden,
that Cousins arbitrarily cited scientific references that bolstered his
preconceived notions just as he arbitrarily traced the etiology of his
disease. More serious is Ruderman's contention that Cousins offered no
proof that his therapeutic regimen was responsible for his cure. In the
long run she believes that his account and the curious laudatory
response of the medical community will injure the doctor-patient
More recently, 0.
Carl and Stephanie Matthews-Simonton have presented evidence that
positive mental imagery can be incorporated into a therapeutic regimen
for terminally ill cancer patients. The Simontons first became
interested in imaging in
when Carl Simonton, a
radiation oncologist, heard a prominent immunologist express the idea
that cancer was due in part to a breakdown in immunocompetence. To treat
his leukemic patients, the immunologist extracted abnormal white cells
and applied them to the skin in the
hope of summoning the body's natural
defenses. Remission was higher than with more traditional techniques
prompting Simonton to look more closely at the possible factors
responsible. After researching the area, Simonton arrived at the
tentative conclusion that the best predictor of successful treatment was
a positive attitude toward the treatment regimen and life in general.
Moreover, the beliefs of the patient's family, significant others and
physicians are positively correlated with positive treatment outcome.
Following the notion that one's beliefs limit one's perceptions of
reality and possibility, Simonton began to explore the ways in which he
could change the attitudes of dying people who were depressed,
unaccepted, and overwhelmed by their plight. The course of therapy must
also be attuned to particular psychological factors that the Simontons
believe are etiologic in cancer (1978). "Those predisposing factors most
agreed upon as (negative) personality characteristics of the cancer
1. a great tendency to hold resentment
and a marked inability to forgive;
2. a tendency toward self-pity;
3. a poor ability to develop and maintain
meaningful long-term relationships;
4. a very poor self image.
In the majority of cases the person has
lost a significant loved one."
The Simonton plan involves 4 steps.
First, the individual goes through a period of orientation in
which he is encouraged to bring friends and relatives to the clinic
where they will be introduced to the concepts of stress reduction,
meditation, visualization and the notion that physical disease
represents the complex interplay of P/LS and physical factors. The
patient is introduced to the idea that to some extent, physical
integrity is compromised by unrelieved psychological tensions so that in
a sense, the person has contributed to his illness. Later, therapy
attempts to capitalize on the logic that if a person has helped produce
his condition, he can also help
ameliorate it. In the second phase, the person is instructed in
visualization and imagery exercises arid instructed to read "The Will
to Live" by Arnold Hutschneker (1953). For those patients who do
return (approximately 50%), the third stage involves group therapy
sessions every day for 5 days. The content of these sessions
deals with imagery exercises concerning psychosocial factors and
lifestyle changes. The fourth stage finds the patient leaving the
clinic to return home and practice what has been learned in the prior
3 stages. Patients commit themselves to one year of treatment and
return every 3 months for 3 days of intensive group
sessions. It should be noted that the Simonton approach requires that
the patient continue to participate in the prescribed medical treatment
plan which may consist of radiation and chemotherapy.
Since imagery is
central to both the efficacy of this approach and some of the
controversies surrounding it, I would like to describe the technique in
some detail. First, patients are taught a simplified form of autogenic
training which involves deep muscle relaxation induced by
autosuggestion (Pelletier, 1977, 1979). The person subvocally repeats
the word "relax" while passively focusing on a tense body part. Through
proper training and practice, the person learns to release tensions on
cue. Once relaxation is induced, the individual is asked to visualize a
peaceful scene, thus enhancing psychological tranquility. Next the
person is asked to visualize the illness in whatever form it may appear
to him, then visualize the medical therapy attacking and conquering the
disease. The precise content of the imagery is less important than the
theme: treatment conquering disease. Thus, treatment may be visualized
as bullets are showering a hamburger or voracious sharks (lymphocytes)
attacking feeble grey fish (cancer cells).
Lawliss (1978) have formulated a test called IMAGE-CA which
assembles patients' subjective reports and scores them in order to
provide clinicians with a method of understanding the role patients play
in their treatment. The administration of IMAGE-CA in conjunction with a
battery of other psychodiagnostic tests shows that the psychological
factors outlined by the Simontons (1975) are better predictors of
treatment outcome than other medical analyses. Basically, the procedure
involves asking patients to go through relaxation exercises while
focusing on subjective cancer imagery. Then they are asked to draw the
images. Fourteen factors were subjected to standardization.
They are "vividness,
activity and strength of cancer cell; vividness and activity of
white blood cell; relative comparison of size and numbers of
cancer and white cells; vividness and
effectiveness of medical treatment; degree of symbolism;
overall strength of imagery, regularity of imagery process; and
clinical opinion related to prognosis, based on imagery factors"
(Achterberg and Lawliss, 1978). Common elements of imagery
that are predictive of good prognosis are images that
included "white knights", "Vikings", and large powerful animals
such as dogs and bears aggressively assaulting cancer cells.
Those who saw white blood cells as more vivid than cancer cells
had a better prognosis than those who saw the cancer cells
as being more vivid.
To date, the
Simonton's claim to have extended the life expectancies of
approximately 100 patients judged to have less than a year to
live. Average survival time is approximately 20 months. Of the 63 still
surviving, 22.2% had no evidence of disease while 19% were
in remission. Despite these apparently impressive data, the Simontons
have been beset by criticisms on both scientific and ethical
grounds. Let us assume for the moment that the results do
speak favorably for their approach and the idea that P/LS are
etiological factors in cancer. What is the mind-body
connection that might account for these findings?
psychophysiological mechanisms are sketchy at best, one line of
research suggests compromised immunocompetence. The hypothalamus, an
important element in the neural and hormonal control of emotionality and
systemic physiology, receives stress input via cortical
pathways. This triggers sympathetic arousal via descending nerve
pathways. The net result is the mobilization of bodily resources
appropriate to the classic fight or flight reaction. Among the numerous
physiological concomitants it seems that the secretion of stress
hormones (epinephrine and norepinephrine from the adrenal medulla are
crucial in maintaining a positive feedback loop accelerating the already
accelerated hypothalamic influence. When stress cannot be
diminished, the hypothalamus hormonally influences the pituitary to
secrete ACTH (adrenocorticotrophic hormone), which in turn stimulates
the adrenal cortex to secret glucn-P-'4oq;ds
and steroids, which have the effect of resisting a variety of
stressors and maintaining physiological processes while paradoxically
suppressing the body's immune response. Research by Solomon at Stanford
(1969) and Stein, Schiavi and Camerino at Mt. Sinai School of
Medicine (1976) suggests that
while the influences are certainly multifactorial, one important element
seems to be the linkage between the hypothalamus and thymus gland which
functions in the surveillance of microorganisms and antibody
production. Any compromise of thymus functioning should negatively
influence thymus integrity, thereby suppressing the immune response. The
result could be cancer. Numerous studies with lab mice show that when
the hypothalamus is lesioned, thymus activity is inhibited, rendering
the animal susceptible to certain forms of cancer (Solomon,
1969; Amkraut and Solomon,
1975). Recent research by Riley
(1975, 1961) has shown that
environmentally induced stress in lab mice leads to a breakdown in
immunological apparati and a greater risk of cancer. Keller, et al.
(1981), has also provided
evidence in mice that lymphocyte production can be suppressed by
subjecting animals to a graded series of stressors.
ADDITIONAL STUDIES RELATING P/LS TO CANCER
The work of the Simonton's and Achterberg
and Lawliss is appealing because it is consistent with a death-defying
movement which overlaps with the so-called "self-help" movement which
burgeoned in the 1970's. The
credo is that since each person has virtually unlimited potential, he
can cure himself if only he could find a way to tap his powers. One way
would be to adopt a positive attitude. This idea is pleasing but
impossible to verify. The sobering alternative is to assume that man is
a powerless pawn of nature. Perhaps the important point is that what
one perceives to be real is reality for that person. If in fact the
Simonton approach is nothing more than placebo, still the patient is
more concerned that he is getting better than he is about satisfying the
scientific curiosity geared toward determining why he is getting
better. I will present criticisms to the Simonton approach in a later
section. I would now like to present other data bearing on the
relationship between F.LS and cancer. It would be virtually impossible
to review the multitude of factors that have been implicated, and the
numerous studies that are relevant. In addition, most of the studies are
seriously flawed methodologically, making data interpretation risky.
Therefore, it r,-,ay be more instructive to focus on research areas, and
then spend some time on the more methodologically sound studies. For a
thorough account of research trends and future possibilities in this
area, the interested reader is urged to consult Fox (1978). Much of the
forthcoming information has been derived from this source and a complete
list of references can be found therein.
Some studies address personality factors,
both stable and emerging, while the majority of studies address
transient or long-term life events, hypothesizing that the stress
resulting from particular experiences increases one's susceptibility to
cancer. In these studies, cancer is considered to be the result of
immunosuppression. Other studies focus on personality factors that are
reflective of greater reactivity to stressors again by immunosuppression.
This third type of study conceptually blends personality and life-stress
factors. Many of these studies adopt a psychodynamic stance by
explaining cancer development in terms of denied form of
disease in a particular organ system. Such people show a poor outlet
for emotional discharge, reduced aggressive expression, and diminished
introspection into their emotional difficulties. Most show depression,
apathy, and a sense of hopelessness. Such findings are not unlike those
observed by the Simontons.
Study of the relationship between stress
and disease began in earnest with the work of Selye (see 1974). Evidence
has proliferated that stressful occupations, job situations and other
life changes are associated with a greater incidence of disease in
general. Holmes and Rahe (1967) have attempted to assess the
relationship between psychosocial stress and disease by having subjects
rate the impact of 43 events on their lives. Impact scores are assigned
and the subjects are followed for a period of time. Generally speaking,
higher impact scores are associated with a higher future disease
incidence. When this approach is applied to cancer, the results are
contradictory, showing as many negatives as positives and making one
wonder about how well life-stress can predict cancer. There are simply
not enough data to infer causation.
Many of the social stresses that have
been implicated in the causation of mental illness have also been
suspected in the etiology of cancer. Some putative factors are:
insecurity, poverty, loss of social status, social isolation, work role
incompatibility, loss of self-esteem, disrupted family situations, and
social change. However, one prospective study of "neurotics" discharged
from the army in 1944-45 demonstrated that these people showed no greater.
incidence of cancer 24 years
later than control subjects (Keehn,
1974). Kissen (1966)
found no differences in neuroticism between lung cancer patients and
other hospitalized patients.
In studying the relationship between
social stress and cancer, particular types of stressor have been
observed. Meares (1975) has
expressed the view that the dominancesubordination factor
may be critical with submission increasing vulnerability to
psychosomatic disease in general. It is conceivable that long-term
frustrations in marriage, child-rearing, and job may fulfill one of the
more important criteria for a carcinogen; long-term stimuli acting as
promoters of cancer development. Appropriate to this notion is the
finding that male and female stomach cancer had a shift toward lower
androgen-estrogen ratios and a reduced rate of baldness also predicted
by androgen-estrogen levels (Wakisaka, et _al.,
1972). Abse, et al.
(1974) found that men in his
cancer group were hypoassertive. These findings are in line with
Seligman's notion of "learned helplessness" mentioned previously and may
be consistent with Lazarus' notion that being able to anticipate events
or stressors even if one cannot control them is a form of symbolic
coping. It might be predicted that if stress can induce cancer, being
able to cope should reduce the risk. Is this, in fact, what the
Simonton's have accomplished?
REVIEW OF IMPORTANT PROSPECTIVE STUDIES
Thomas and Duszynski
(1974) prospectively studied
1337 Johns Hopkins medical
students between 1948-1964, by
having each subject complete a questionnaire concerning family attitudes
as perceived by the subject. Three family attitude scales were derived:
closeness-to-parents, emotional demonstratives, and matriarchal
dominance. Five disordered groups were then defined: suicide,
mental illness, hypertension, malignant tumor, coronary occlusion. The
most impressive finding was that the suicide, tumor, and mental illness
groups scored very low on the closeness-to-parents scale indicating a
perceived lack of closeness to parents. The relationship was most
powerful for the tumor Croup suffering from several types of
cancer such as leukemia, seminoma, basal cell carcinoma, lymphoma,
melanoma, carcinoma of the pancreas and astrocytoma. In this
study every negative family attitude was more common in the tumor group
than in any other. Negativity was also inferred from failure to check
positive attitudes. Some of the positive attitudes rarely checked were:
companionable, warm, understanding, steady, admirable, confiding,
comfortable, and congenial. Some of the negative attitudes were:
detached, unpredictable, dislike, rebellious, hurt, and disagreeing.
Thomas and Buszynski view these findings as consistent with many of the
interpretations thus far presented. LeShan (1966) has hypothesized that
early in life a child's ability to relate to others is damaged resulting
in feelings of isolation, and the expectation that relationships bring
pain and rejection and a sense of hopelessness and helplessness. Later,
when considerable emotional energy is invested in a meaningful
relationship, and then the relationship dissolves due to the death of a
spouse, loss of a job, or a child leaving home, the sense of despair
resurfaces. This hypothesis is virtually identical to the concept of "anaclitic
depression" espoused by many psychodynamicists
CRITICISM OF SIMONTON APROACH AND P/LS RESEARCH
In a previous section I somewhat
uncritically presented the work of the Simontons. However, the reactions
of the scientific community have not been favorable and in many
cases have been downright disdainful. Let us review some of the
criticisms of the Simonton approach and PILS research. Despite the
convictions of the Simontons, no consistent personality profile has
been found that would allow us to talk of cancer-types. The profiles
described in this chapter could be indicative of any number of
psychosomatic disorders. Moreover, the profiles have often been deduced
from people already suffering from cancer making it entirely possible
that cause and effect have been misconstrued. I will elaborate. Early
cancer affects the patient both by his awareness of having the disease,
and through physiological changes resulting from complications, surgery
or chemotherapy. In advanced stages there is often pain and
debilitating psychological disequilibrium due to one's knowledge of
his condition and the disruption of his life. There are also
endocrinopathies resulting in the secretion of hormones with actions
similar to ACTH, epinephrine, cortisol, parathormone and insulin. Some
cancers produce encephalopathy which along with endocrine dysfunctions
may produce ti7e oft-seen psychiatric symptoms of anxiety, depression,
disorientation, memory impairment, depressed intellectual functioning,
and mood disturbances. Davies (1973)
found that, even though the clinical picture showing an apathetic
giving-up syndrome correlated with the loss of significant loved one,
it also correlated with greater physical illness, hematological
disturbances and reduced sleek. Loss did not correlate with tumor.
Nehmiah and Sifneos (1970) described a psychological condition associated with certain
illnesses in which the patient finds it difficult to use language to
express emotions and engage in emotional fantasy. The authors have
posited a neuroanatomical break between neocortex, the locus of
language, and paleocortex, the locus of emotionality. In light of our
previous discussion of P/LS factors as etiologic, the following
question now becomes very interesting. Are we looking at psychosomatic
cancer where P/LS produce disease or are the connection somatopsychic,
where the disease and its psychophysiological concomitants and
byproducts lead to the psychological and behavioral effects?
In conclusion to this section it can be
said that there are differences between cancer and non-cancer patients.
But considering the state of science that is probably all we can safely
Numerous studies have shown connections
between P/LS and hormones, but few have drawn a link to cancer. Other
studies have shown that the immune system can be affected by altering
the activity of particular brain regions, but it has also been shown
that the immune system plays a limited role in inhibiting or promoting
cancer. Immunological deficiencies can produce a variety of cancers but
rarely are they the most common types: lung, breast, colon (Fox, 1978).
Cancers of the Immune system are more likely. In short, a causal link
among stress, immunosuppression and cancer has not been satisfactorily
demonstrated. This casts a shadow on the Simonton approach and the whole
area of cancer and immunosuppression.
If the above criticisms were not enough,
others include unsuccessful attempts of others to replicate Simonton's
finding, the absence of adequate control groups, and inappropriate
statistical analyses. In defense, I wish to address some of these
criticisms. While scientific proof should be required, such proof would
be difficult, if not impossible to come by. It would require massive
prospective studies wherein subjects without evidence of neoplasm are
carefully studied and assessed physically and psychologically over many
years. Whom would we get to participate in this study? Who would submit
to the constant intrusion necessary to adequately explore the problem?
The task would be monumental.
On the issue of replication, nobody would
argue the need for replication; yet it is well known that researchers
tend to find what they would hope and need to find rather than what is
the case. This is easy to understand when job, money, reputation, one's
career are on the line. In general, the medical profession has always
tried to deflect outsiders from muscling in on their territory. Besides,
medical science (and probably all science) is somewhat resistant to
change, especially when there are assaults on time-honored methods and
when these assaults emanate from sources outside of that science. In the
case developed here, imagery has never found a place in traditional
western medical science.
Sampling, assignment of subjects to one
group or another and control are always an area vulnerable to criticism.
Assuming that sampling procedures were adequate, we would yet run into
the ethical consideration of withholding treatment from roughly half of
our subjects (controls). If in fact the treatment does appear to be
sound, we would be faced with the dilemma of having to satisfy the
demands of scientific rigor while forsaking those who may have been
Regarding studies showing no increase in
risk factor among patients whose immunocompetence has been surgically
compromised, and the observations that high-stressed individuals do not
always show an increased incidence of cancer, I would like to state that
while these are valid criticisms that must be faced, they are by no
means clearly indicative of a flaw in the Simonton approach. Since there
is no evidence that we can equate psychological and physiological
parameters across studies, comparisons become risky. If the holistic
approach has any merit, one could argue that if disease is
multifactorial then no single factor by itself is capable of producing
any condition. Accordingly, stress per se produces nothing.
Finally, most of the research showing a
link between stress and disease has been conducted with lab mice. I
trust that the reader realizes the problems inherent in extrapolating
from animals to humans. Many cancer researchers argue that animal
cancers are in many ways not like human cancers. Riley has made the
following rejoinder. "Although it may be hazardous to extrapolate
biological findings from mice to other species, it would be equally
imprudent to ignore the many physiological similarities and analogous
biochemical relationships that evolutionary biologists have
demonstrated in animals belonging to the same phyla. The fundamental
biological principles that are further delineated through the study of
animal models may be expected to have application to man" (Riley, 1981).
I guess we must be careful not to throw out the baby with the bath
Other criticisms not directly based on
methodological flaws state that the Simonton method is analogous to
medieval evangelism in which sin has been replaced by depression, denial
and redemption, placing it in the vein of the self-help movement of the
'60's and '70's. Many are appalled that the Simonton's are committing a
cruel fraud by playing a game called "blame the patient". It is enough
that the patient is suffering, dying, and blaming himself already.
What he needs least is another slap in the face. Even if patients
accept their role in the production of their illness, they will develop
an illusion of mastery that will be shattered at the moment of truth
What will become of the Simonton method
One factor bearing on future appeal is
the burden or scientific proof in a world where statistics speak
loudest. Pelletier (1977) discusses a statement by Simonton regarding
the issue of scientific proof in which Simonton tells of a psychiatrist
who was using an unorthodox approach in the treatment of schizophrenia.
Under pressures from colleagues to substantiate the efficacy of his
approach, the psychiatrist organized a symposium of prominent scientists
to deal with the question of what constitutes scientific proof. One
response was particularly interesting. The letter stated that "the
question is much too difficult for me" and went on to state that "I
couldn't be of much help". The letter was signed "Albert Einstein".
Regarding the issue of ethics, it seems
that the Simonton approach will be viewed more favorably if it proves
to work. The more scientifically sounds the method, the more ethical it
will be to utilize it within limits. Scientific proof is not the only,
nor should it be the only, consideration. As with most medical and
psychotherapeutic interventions, the price one pays in the hope of
reaping greater rewards is a sticky problem. One only has to look at
recently publicized treatments such as laetrile for cancer, marijuana
for the side effects of chemotherapy, amphetamines for obesity and
psychosurgery for intractable psychiatric disorders. Does the end
justify the means? What initially starts out as a scientific issue
ultimately becomes a legal, political, ethical, economic and
sociological issue involving physicians, patients, lawyers, clergy,
drug companies, politicians, civic groups ... ad nauseam.
Simonton's attitude is that considering
the condition of the patients, it is worth a try. The Simonton method is
clearly controversial but it seems that controversy is only generated
when matters are not clearly black or white. If the method were either
as "terrible" or "effective" the opposing parties claim, controversy
would not exist.
In conclusion, elucidation of the
relationships among P/LS, cancer and dying will require much more than
an attempt at scientific corroboration. What is needed is a cognitive
shift or change in mind-set that will permit a fresh look at the problem
from the holistic viewpoint. For many involved in research, this may
prove difficult if not impassible, since for a variety of reasons
people tend to become cognitively stale and unable to reconceptualize.
The possibility exists that there is no significant relationship among
the variables discussed. However, that determination cannot be made
until more data are accumulated. It seems as though even data may be of
little help if those data continue to be viewed through the same pair,
of tinted glasses. Knowledge often comes from technological advances.
But it also comes from changing one's glasses.
Abse, D. W., Wilkins, M. M., VandCastle, R. L., Buxton, W. D., Demars, J.
P. Brown, R. S. and Kirschner, L. G. Personality and Behavioral
characteristics of lung cancer patients. J. Psychosom. Res. 18: 101-113,
Achterberg, J. and Lawliss, G. F. Imagery of cancer. Institute
for Personality and Ability Testing, Champaign, I11. 1978.
Amkraut, A. and Solomon, G. F. From the symbolic stimulus to the
Pathophysiologic response: Immune Mechanisms. 1nt. J. of Psychiatry in
Med. 5: no. 4, 541-563, 1975•
American Psychiatric Association, Diagnostic and Statistical Manual. Third
Edition. Washington, D.C. 1980.
Bandura, A. Self-Efficacy: Toward a Unifying of Behavioral Change.
Psych. Rev.84: 191-215, 1977.
Chesney, M. A., Black, C. W., Chadwick, J. H. and Rosenman,
R. H. Psychological Correlates of Type A Behavior. J. Behav. Med.
4: no. 2, 217-229, 1981.
Costello, C. G. Depression. Loss of Reinforcers or Loss of Reinforcers
Effectiveness? Beh. Therapy 3: 240-247
Cousins, N. Anatomy of An Illness (as perceived by the patient) New
England J. Of Med. 295: no. 26, 1458-1463, 1976.
Davies, R. K., Quinlan, D. M., McKegney, F. P. and Kimball, C.P.
Organic Factors and Psychological Adjustment In Advanced Cancer Patients.
Psychosom. Med. 35: 464-471, 1973.
Ferster, C. B. Classification of Behavioral
Pathology. In: L. Krasner and L. P. Ullman (eds.). Research in Behavior
Modification. Holt, Rinehart and Winston, New York, 1965.
Fox, B. H. Premorbid Psychological Factors and Cancer Incidence: A
Background for Prospective Grant Applicants. J. Beh. Med. March: 45-133,
Freud, S. Our Attitude Toward Death. Collected Papers, vol. 4, Hogarth:
London, 1915 (1956).
Freud, S. Mourning and Melancholia. Collected Papers, vol. 4, Basic Books,
New York 1917 (195)) •
Friedman, M. and Rosenman, R. H. Type A behavior and your Heart. Fawcett
Crest, New York, 1917
Holden, C. Cousins' Account of_ Self-Cure Rapped. Science
214: no. 4523 892, 1981.
Holmes, T. H. and Rahe, R. H. The Social Readjustment Rating Scale. J.
Psychosom. Med. ll: 213-218, 1967.
Hutschnecker, A. The Will To Live. Crowell, 1953, New York: Cornerstone
Kastenbaum, R. and Costa, Jr., P. T. Psychological Perspective on Death.
Ann. Rev. Psychol. 28: 225-249, 1977
Keehn, R. j., Goldberg, I. D. and Beebe, G. W. Twenty-Four Followups of
Army Veterans with Disability Separations for Psychoneurosis in 1944.
Psychosom. Med. 16: 2745, 1974.
Keller, S. E., Weiss, J. A. Schleifer, S. J., Miller, N. E. and Stein, M.
Suppression of Immunity by Stress: Effect of a Graded Series of Stressors
on Lymphocyte Stimulation in the Rat, Science 213: no. 4514, 13971400,
Kubler-Ross, E. On Death and Dying. Macmillan, New York, 1969.
LeShan, L. An Emotional Life-History Pattern Associated With Neoplastic
Disease. Ann. N.Y. Academy of Sci. 125: 780-793, 1966.
Lewinsohn, P. K. A Behavioral Approach to Depression, In: R. S. Friedman
and M. M. Katz (eds.): The Psychology of Depression: Contemporary Theory
and Research, John Wiley, New York, 1974.
Meares, R. A Model of Psychosomatic Illness. Med. J. Aust 2: 97-100, 197.
Nehmiah, J. C. and Sifneos, P. E. Affect and Fantasy in Patients with
Psychosomatic Disorders. In: 0.W. Hill (ed.), Modern Trends in
Psychosomatic Medicine, vol. 2, Appleton-Century-Crofts, Nevi, York,
'Pelletier, K. R. Mind As Healer, Mind As Slayer. Dell: New York, 1977.
Pelletier, K. R. Holistic Medicine. Delacorte Press: New York, 1979.
Riley, R. Psychoneuroendocrine influences in Immunocompetence and
Neoplasia. Science 212: no. 5, 1100-1109, 1981.
Scarf, M. Images That Heal: A Doubtful Idea Whose Time Has Come.
Psychology Today 14: no. 4, 1980.
Seligman, M. E. P. Helplessness: On Depression, Development and Death.
San Francisco, W. H. Freeman, 1975.
Selye, H. Stress without Distress. Lippincott: New York, 1974.
Shneidman, E. S. Suicide, Lethality, and The Psychological Autopsy. In:
Aspects of Depression, E. S. Shneidman and M. Ortega, Little Brown,
Shneidman, E. S. Death of Man. Quadrangle/The New York Times Book Co.,
New York, 1973.
Simonton, 0. C., Matthew Simonton, S. and Creighton, J. Getting Well
Again. J.P. Tarcher, Los Angeles, 1971
Solomon, G. F. Emotions, Stress, The Central Nervous and Immunity. i1. Y.
Acad. Sci. Ann. 164: no. 2, 335-343, 1969.
Stein, M. R., Schiavi, C. and Camerino, M. Influence of Brain and Behavior
on the Immune System. Science 191: 435-440, 1976.
Thomas, C. B. and Duszynski, K. R. Closeness to Parents and the Family
Constellation in a Prospective Study of Five Disease States: Suicide,
Mental Illness, Malignant Tumor, Hypertension, and Coronary Occlusion.
Hopkins Med. J. 1 4: 251-270, 1974.
Wakisaka, J., Inokuchi, T. and Kazizoe, K. Correlation Between Cancer of
the Stomach and Alopecia. Kurume Med. J. 19: 245-251, 1972.
Weisman, A. On Dying and Denying. Behavioral Publications, New York, 1972.
Return to: Table
of Contents for the Online Textbook
© Copyright Philip A. Pecorino 2002. All rights
Web Surfer's Caveat: These are
materials intended for class use. They are not intended for
publication or general distribution